Tetanus

Definition of Tetanus: A non - communicable/infectious disease causing sustained muscular spasm, contraction and convulsions. Derived from Greek word tetanos - stretch. Causes: Contaminated wounds, llacerations, injection sites, aabrasions, burns, frostbites, fforeign bodies, surgeries and unhygienic child births

Epidemiology Host: Humans, domestic & wild animals Causative Organism: Clostridium tetani a gram positive, spore-forming bacteria. Found in two forms: Dormant form (spores) Active form (vegetative).

Communicability: Not directly transmitted from person-person. Age: Affect any age. Distribution: Tetanus occurs worldwide and is endemic in many developing countries. Incidence in developed countries is low due to effective vaccination programs.

Path physiology Spores enter through puncture wounds Inside the body spores develop into active form that multiply and produce a powerful toxin tetanospasmin (a poison that attacks nervous system and blocks nerve signals from the spinal cord to and from the muscles). 

Case definitions Probable case: In the absence of a more likely diagnosis, an acute illness with muscle spasms or hypertonia, OR diagnosis of tetanus by a health care provider, OR Death, with tetanus listed on the death certificate as the cause of death Confirmed case: There is no definition for “confirmed” tetanus case.

History: In 1889 Japanese bacteriologist Kitasato, isolated tetanus bacterium. In 1897, Edmond Nocard showed tetanus antitoxin produces passive immunity (used during World War I).

4 types of Tetanus: Generalized tetanus: 1 Generalized tetanus: Most common & severe form affects all skeletal muscles 2 Local tetanus: Manifests with muscle spasms at or near the infected wound 3 Cephalic tetanus: Affects one or more muscles in face in 1 or 2 days after a head injury or ear infection. Lockjaw occur that can easily progress to generalized tetanus. 4 Neonatal tetanus: Is similar to generalized tetanus except that it affects a neonate

1. Generalized tetanus: Lockjaw: spasm of facial muscles. 2. Risussardonicus: A sardonic smile (facial muscle spasms)

Cont, 3. Opistotonus: Progressive and intense muscle spasm leads to characteristic arching of back and fractures.

2: Cephalic Tetanus: Rare, involves 7th cranial nerve Lockjaw, weakness of facial muscle occurs In 2/3rd of cases, generalized tetanus develops

3: Symptoms of Localized Tetanus In localized tetanus, muscle spasms occur at or near the site of the injury. This condition can also progress to generalized tetanus.

Diagnosis: Diagnosis is based on clinical symptoms. The bacteria, is recovered from wound in only 30% of cases.

Spatula test: Posterior pharyngeal wall is touched with soft-tipped instrument. Negative test: Elicits a gag reflex, patient tries to expel spatula. Positive test: Results in the involuntary contraction of the jaw (biting down the spatula)

Treatment: Wound care Medications Supportive care Vaccination Wound care  Clean wound thoroughly by soap & water to remove dirt, foreign bodies and dead tissue from wound to prevent growth of tetanus spores.

2. Medications Antibiotics. To fight tetanus bacteria. Sedatives. Sedatives to control muscle spasms. Other drugs. Like magnesium sulfate, beta blockers & morphine to regulate involuntary muscle activity, regularize heartbeat and breathing IV fluids 3. Supportive therapies: Long period of treatment in an intensive care settings. E.g. ventilator

Vaccinations Anti Tetanus vaccine Tetanus toxoid (TT)

Anti Tetanus vaccine Tetanus antitoxin is an immunoglobulin. Neutralizes the toxin produced by Clostridium tetani.  Used to provide temporary passive immunity. Contraindicated: not be used for prophylactic use or when anti tetanus immunoglobulin is available or the patient is allergic (give test dose) The dose is usually from 1500 - 6000 units.

Tetanus Toxoid Best tool to prevent tetanus Recommended for people of all ages, with booster shots throughout life. After three doses almost everyone is immune.  Pregnant women should be immunized against tetanus this can prevent neonatal tetanus.

EPI for children: A Pentavlent vaccine is 5 vaccines conjugated in 1 to actively protect infants & children from 5 deadly diseases.  (Homophiles Influenza B, Pertussis, Tetanus, Hepatitis & Diphtheria) PENTAVLENT - 1 at 6 weeks PENTAVLENT - 2 at 10 weeks PENTAVLENT - 3 at 14 weeks The booster at 4 - 6 year of age, than every 10 years.

Expected duration of protection Dose of TT or Td When to give Expected duration of protection 1 none 2 2nd dose at least four weeks after TT1 1 – 3 years 3 At least six month after TT2 or during subsequent pregnancy. At least 5 years 4 As early as possible At least 10 years 5 At least one year after TT4 or during subsequent pregnancy For all childbearing age years and or longer

Complications: Once tetanus toxin bonds to nerve endings it is impossible to remove. Complete recovery requires growth of new nerve endings and takes several months. Fractures due to severe muscular spasms. Prolonged immobility by high doses sedatives leads to permanent disability. Brain damage in infants. Respiratory failure is the most common cause of death.

Prevention Tetanus can be prevented through immunization Neonatal tetanus can be prevented by immunizing women of childbearing age with TT, either during pregnancy or outside of pregnancy. This protects the mother and – and through a transfer of tetanus antibodies to the fetus – also her baby.

Prognosis: 25%-50% of people with generalized tetanus will die. Very young & old tend to have more severe disease. Death is usually due to respiratory or cardiac failure. Intensive medical care improves the prognosis. Data on worldwide neonatal deaths is not complete due to poor data collection in many countries, however, it is about 60%-80%.

Tetanus neonatorum

Neonatal Tetanus: Deadly disease of newborn, fatality is 70- 100 % About 4 million neonatal deaths occur/year Accounts for 2/3rd of infant mortality & 40% under 5 mortality. Danger to neonates of non immunized mothers Deaths occur before infant is two weeks old Common in developing countries and poor communities. Causes are unsanitary cord-care and unsterile instruments. Not reported among neonates in developed countries.

Symptoms Symptoms commonly appear on 3rd day after birth & include: Difficulty in swallowing Irritability, muscle spasms & rigidity Poor sucking Convulsions

Treatment: Clean wounds thoroughly. Give valium to reduce severity of spasms. Tetanus immunoglobulin and tetanus antitoxin. Antibiotics. Supportive treatments like oxygen and NG tube Tracheotomy may be performed for obstruction of airway.

Maternal Neonatal tetanus (MNT) The MNT Elimination Initiative was launched by UNICEF, WHO in 1999. Aim: achieve < 1 NT /1000 live births in every district. In August 2015, MNT remains a major public health problem in 21 countries.

The strategies Strengthening routine immunization of pregnant women with tetanus toxoid vaccine TT Supplementary Immunization Activities (SIAs) in selected high risk areas, targeting women of reproductive age with 3 properly-spaced doses of the vaccine Promotion of clean deliveries and clean cord care practices

Key facts Tetanus is acquired when the spores of the bacterium Clostridium Tetani infect a wound or a new-born's umbilical stump. The spores are universally present in the soil. Spores germinate to produce an exotoxin, tetanospasmin, that causes rigidity & spasms of voluntary skeletal muscles People of all ages can get tetanus but the disease is common and serious in new-born babies.

Neonatal tetanus is a significant problem in developing countries due to poor umbilical stump hygiene and lack of maternal immunization. Neonatal tetanus requires treatment in a medical facility, often in a referral hospital. Acute condition requiring intensive care Prevention is by immunization